Nursing News

Progress Made in Removing Barriers to NP Practice

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By Debra Wood, RN, contributor

July 9, 2014 - Nurse practitioners made significant progress this year in breaking down scope of practice barriers, with two states approving autonomous NP practice and more legislatures considering such action for NPs and other advanced practice registered nurses (APRNs).

“We’ve made great progress, and we still have the rest of the year,” said Ken P. Miller, PhD, RN, CFNP, FAAN, president of the American Association of Nurse Practitioners (AANP). “We had two states make it. We can take the lessons learned and apply them to other states.”

The governors of Minnesota and Connecticut signed legislation removing the need for career-long collaborative agreements with a physician, bringing the number of states with autonomous practice to 19, plus the District of Columbia.

“Ensuring RNs’ full practice authority is important for patients,” said Janet Haebler, MSN, RN, associate director for state government affairs at the American Nurses Association (ANA). “Permitting nurses to practice fully increases access to care.”

Janet Haebler, MSN, RN, said legislative wins for nurse practitioners occurred in several states this session.

Lisa Byrd, PhD, FNP-MC, GNP-BC, president of the Gerontological Advanced Practice Nurses Association (GAPNA), added, “Our aim is to care of patients and help them get the best health care they are able. Many of our patients are underserved and need someone who can help navigate the health care system.”

After more than four decades of improving patient access, nurse practitioners are emerging as the answer to many of our health care problems, and legislators are starting to take notice, said Margaret (Peg) O'Donnell, DNPs, FNP, ANP, BC, FAANP, senior nurse practitioner, South Nassau Communities Hospital in Oceanside, N.Y.; Southern New York State representative, AANP; and Region 7 director, Nurse Practitioner Association of New York State.

“The nursing philosophy coupled with advanced medical acumen is the perfect formula for progress, and a clear solution for patient-centered affordable health care,” said O’Donnell, adding that there has been tremendous legislative progress for NPs in New York State, and across the country.

Nurse practitioner/advanced practice trends

Michele Pedulla, DNP, ARNP, CPNP-PC, a professor of nursing at Kaplan University in Orlando, Fla., credits much of the progress, although slower than desired, to the Campaign for Consensus from the National Council of State Boards of Nursing, which aims to bring uniformity to state laws for NPs and align advanced practice registered nurse (APRN) regulation with the major elements of The Consensus Model for APRN Regulation. She reported that 10 states are in 100 percent compliance in 2014, a jump from five states in 2013; 12 states and the District of Columbia are 75 percent to 96 percent compliant, a jump from nine in 2013.

Pedulla also cited a 2014 policy paper from the Federal Trade Commission in which state legislators were strongly cautioned of the harm in limiting APRN scope of practice.

“In this paper, there was strong support for the APRN as a primary health care provider, citing issues including the shortage of providers, the need for improved competition for the benefit of the consumer, as well as allowing for the choice to include the collaborative effort of the physician, not as a requirement for practice as an APRN,” Pedulla said.

Michele Pedulla, DNP, ARNP, CPNP-PC, credits the NCSBN's Campaign for Consensus with prompting many of the legislative changes.

Byrd reported that “GAPNA has seen an increase in the value of the nurse practitioner role in the health care arena.”

Winifred V. Quinn, PhD, director of advocacy and consumer affairs at the Center to Champion Nursing in America and overseer of the team that supports the Campaign for Action's 51 Action Coalitions, reported a trend among states to remove the contractual barriers between APRNs and physicians, but only after a period of time.

“APRNs must pay physicians for these contracts, and the contracts also prohibit some actions that these nurses can take to help their consumers,” Quinn said.

“Nursing professionals, like physicians, self-regulate and know when they do not possess the specialty expertise and need to refer to another provider,” Haebler added.

State by state

While the Minnesota legislation (Senate File 511) removed mandatory collaborative management agreements after NPs complete 2,080 hours in an integrated clinical setting, it included concessions to state medical associations, such as continuing the requirement for certified registered nurse anesthetists (CRNAs) proving chronic pain management activities to work under a career-long collaborative agreement with a physician.

The Connecticut legislation (Senate Bill 36) requires a three-year collaborative agreement with a physician for both new nurse practitioners and those new to Connecticut, which AANP said will “limit the state's ability to recruit and retain enough nurse practitioners to meet the growing needs of its patient population, especially those in medically underserved communities.”

Winifred V. Quinn, PhD, explained that if laws were modernized, APRNs would be able to improve their financial security and medical consumers who visit APRNs would be healthier.

“However, it still requires APRNs to have four or more years of experience to prescribe routine medications under the auspices of a physician; and it also mandates that APRNs maintain a contractual agreement with a physician to be able to prescribe controlled substances,” Quinn said.

New York’s budget bill (S 6356) included passage of the Nurse Practitioners Modernization Act, which will allow NPs with more than 3,600 hours of experience to practice without a written collaborative agreement. However, collaborative relationships are still required and nurses must attest to having one.

“The scope of practice has not changed, but the major barrier to practicing to the extent of our lawful authority has been removed,” O’Donnell explained.

Utah House Bill 143 removed the one-year internship that mental health nurse practitioners needed to have with a psychiatrist, Quinn said. Also, Utah Medicaid will now reimburse nurse practitioners.

Additionally, Ohio will now allow NPs to admit patients to the hospital; Pennsylvania will let NPs lead medical homes; and New Hampshire and Illinois will allow NPs to sign Physician Orders for Life-Sustaining Treatment.

Next steps

Enabling nurses and nurse practitioners to work to the full extent of their knowledge and experience was one of the recommendations of the Institute of Medicine's Future of Nursing: Leading Change, Advancing Health report. Many of the state Campaign for Action coalitions have focused their efforts on educating elected officials and convincing them to change the laws, which will improve access to care.

“The Campaign for Action is engaging the business community in the efforts to educate the public and policy makers about the value of APRNs,” Quinn said. “AARP will continue to work with the business community, nursing leaders and other stakeholders to modernize more state and federal laws to help improve consumers' access to care and to contain costs.”

On the federal level, NPs are making progress toward the passage of Home Health Legislation (HR 2504 and S 1332), which will allow for NPs to order home health without a physician’s signature on the face-to-face documentation, O’Donnell said.

Additionally, the U.S. Department of Veterans Affairs has proposed policy changes that would grant all VA nurse practitioners full-practice authority. However, they have not yet been implemented, according to AANP.

AANP, ANA and other nursing organizations will continue their efforts to modernize state laws. For instance, Nebraska will be a hot spot. The Nebraska legislature passed Legislative Bill 916 this year, removing barriers to NP scope of practice, but Gov. Heineman vetoed it. Nebraska will have a new governor next year and, Miller said, AANP will try to move the legislation again.

“We will continue to work as hard as we can for nurse practitioners to get the full scope authority,” Miller said. “There is a lot of support coming from the public.”